Healthcare Provider Details

I. General information

NPI: 1811235724
Provider Name (Legal Business Name): MEDICAL SERVICES OF SUFFOLK COUNTY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 RIDGE AVE
PHILADELPHIA PA
19128-1737
US

IV. Provider business mailing address

7300 STATE HIGHWAY 121 STE 370-374
MCKINNEY TX
75070-1987
US

V. Phone/Fax

Practice location:
  • Phone: 215-483-9900
  • Fax:
Mailing address:
  • Phone: 469-557-6183
  • Fax: 469-640-6671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BLAKEMAN
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 469-557-6183